So Rude to download

1. Diagnosis and management
of Hypertension
dr. PJ Samosir (MD)
RIG Tasha
October 08th, 2022

2. Hypertension is defined as systolic blood
pressure (SBP) of 140 mmHg or greater,
diastolic blood pressure (DBP) of
90 mmHg or greater, or taking
antihypertensive medication.
VI JNC, 1997

3. Types of hypertension
• Essential hypertension
– 95%
– No underlying cause
• Secondary hypertension
– Underlying cause

4. Causes of
Secondary Hypertension
• Renal
– Parenchymal
– Vascular
– Others
• Endocrine
(Diabetes
Melitus)
• Miscellaneous
• Unknown

5. Classification

7. Diagnosis Hipertensi
Diagnosis hipertensi ditegakkan bila TDS ≥140 mmHg dan/atau
TDD ≥90 mmHg pada pengukuran berulang di klinik
KATEGORI TDS TDD
Optimal < 120 mmHg dan <80 mmHg
Normal 120-129 mmHg dan/atau 80-84 mmHg
Normal-tinggi 130-139 mmHg dan/atau 85-89 mmHg
Hipertensi derajat 1 140-159 mmHg dan/atau 90-99 mmHg
Hipertensi derajat 2 160-179 mmHg dan/atau 100-109 mmHg
Hipertensi derajat 3 ≥ 180 mmHg dan/atau ≥ 110 mmHg
Hipertensi sistolik terisolasi ≥ 140 mmHg dan < 90 mmHg

8. Who are at risk ?

9. Hypertension:
Predisposing factors
• Advancing Age
• Sex (men and postmenopausal women)
• Family history of cardiovascular disease
• Sedentary life style & psycho-social stress
• Smoking ,High cholesterol diet, Low fruit
consumption
• Obesity & wt. gain
• Co-existing disorders such as diabetes, and
hyperlipidaemia
• High intake of alcohol

10. Why to treat ?

11. Diseases Attributable to
Hypertension
HYPERTENSION
Gangrene of the
Lower Extremities
Heart
Failure
Left Ventricular
Hypertrophy Myocardial
Infarction
Coronary Heart
Disease
Aortic
Aneurym
Blindness
Chronic
Kidney
Failure
Stroke Preeclampsia/
Eclampsia
Cerebral
Hemorrhage
Hypertensive
encephalopathy
Adapted from Dustan HP et al. Arch Intern Med. 1996; 156: 1926-1935

12. Target Organ Damage
 Heart
• Left ventricular hypertrophy
• Angina or myocardial infarction
• Heart failure
 Brain
• Stroke or transient ischemic attack
 Chronic kidney disease
 Peripheral arterial disease
 Retinopathy

13. CVD Risk
 The BP relationship to risk of CVD is continuous,
consistent, and independent of other risk factors.
 Prehypertension signals the need for increased
education to reduce BP in order to prevent
hypertension.

14. Diagnosis

15. Clinical manifestations
• No specific complains or manifestations other than
elevated systolic and/or diastolic BP (Silent Killer )
• Morning occipital headache
• Dizziness
• Fatigue
• In severe hypertension, epistaxis or blurred vision

16. Laboratory Tests
 Routine Tests
• Electrocardiogram
• Urinalysis
• Blood glucose,
• Serum potassium, creatinine, or the corresponding estimated GFR,
and calcium
• Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
 Optional tests
• Measurement of urinary albumin excretion or albumin/creatinine
ratio
 More extensive testing for identifiable causes is not generally indicated
unless BP control is not achieved

17. How to treat ?

18. Treatment Overview
Goals of therapy
Lifestyle modification
Pharmacologic treatment
Algorithm for treatment of hypertension
Follow up and monitoring
Reduce Cardiac and renal morbidity and mortality.
Treat to BP <140/90 mmHg or BP <130/80 mmHg in
patients with diabetes or chronic kidney disease.

19. Life style modifications
• Lose weight, if overweight
• Increase physical activity
• Reduce salt intake
• Stop smoking
• Limit intake of foods rich in fats and
cholesterol
• increase consumption of fruits and
vegetables
• Limit alcohol intake

20. Algorithm for
Treatment of Hypertension
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Drug(s) for the compelling
indications
Other antihypertensive drugs (diuretics,
ACEI, ARB, BB, CCB)
as needed.
With Compelling
Indications
Lifestyle Modifications
Stage 2 Hypertension
(SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually
thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Stage 1 Hypertension
(SBP 140–159 or DBP 90–99 mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
Without Compelling
Indications
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.

21. Choice of Drug
Condition Preferred drugs Other drugs Drugs to be
that can be used avoided
Asthma Calcium channel a-blockers/Angiotensin-II b-blockers
blockers receptor blockers/Diuretics/
ACE-inhibitors
Diabetes a-blockers/ACE Calcium channel blockers Diuretics/
mellitus inhibitors/ b-blockers
Angiotensin-II
receptor blockers
High cholesterol a-blockers ACE inhibitors/ A-II b-blockers/
levels receptor blockers/ Calcium Diuretics
channel blockers
Elderly patients Calcium channel b-blockers/ACE-
(above 60 years) blockers/Diuretics inhibitors/Angiotensin-II
receptor blockers/a- blockers
BPH a-blockers b-blockers/ ACE inhibitors/
Angiotensin-II receptor
blockers/ Diuretics/
Calcium channel blockers

22. Class of drug Main side-effects Contraindications/ Special
Precautions
Calcium channel blockers Pedal edema, Headache Non-dihydropyridine
(e.g. Amlodipine, CCBs (e.g diltiazem)–
Diltiazem) Hypersensitivity,
Bradycardia, Conduction
disturbances, CHF, LV
dysfunction.
a-blockers Postural hypotension Hypersensitivity
(e.g. prazosin)
ACE-inhibitors Cough, Hypotension, Hypersensitivity, Pregnancy,
(e.g. Lisinopril) Angioneurotic edema Bilateral renal artery stenosis
Angiotensin-II receptor Headache, Dizziness Hypersensitivity, Pregnancy,
blockers (e.g. Losartan) Bilateral renal artery stenosis
Antihypertensive therapy: Side-
effects and Contraindications (Contd.)

23. Condition
• Pregnancy
• Coronary heart disease
• Congestive heart failure
Preferred Drugs
• Nifedipine, labetalol,
hydralazine, beta-blockers,
methyldopa, prazosin
• Beta-blockers, ACE
inhibitors, Calcium channel
blockers
• ACE inhibitors,
beta-blockers
1999 WHO-ISH guidelines

24. Causes of
Resistant Hypertension
 Improper BP measurement
 Excess sodium intake
 Inadequate diuretic therapy
 Medication
• Inadequate doses
• Drug actions and interactions (e.g., (NSAIDs), illicit drugs,
sympathomimetics, OCP)
• Over-the-counter drugs and some herbal supplements
 Excess alcohol intake
 Identifiable causes of HTN

25. Low blood pressure is a reading of less
than 90/60mmHg. It does not always
cause symptoms, but you may need
treatment if it does.

26. take home message --------------
• Hypertension is a major cause of morbidity and mortality, and
needs to be treated
• It is an extremely common condition; however it is still under-
diagnosed and undertreated
• Hypertension is easy to diagnose and easy to treat
• Aim of the management is to save the target organ from the
deleterious effect
• Besides pharmacology we have other choices and one has to be
acquainted with that choice
• Life style modification should always be encouraged in all
Hypertensive patients